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. . <br /> � A �> 1� 8 � �A� ��0�'�������t�U ����Uth ����a�mment <br /> ~. .. ,~~ .~, ..v ,~ ' ^ , . <br /> ° --C'-­�':_! NTY-- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility * Caterer <br /> Complete sections Yand 2. /fyour commissary islocated outside ofSan Joaquin County also complete section 3. <br /> Business Name Li c. P I ate# <br /> Owner/Operator Namena 1) /n fl e 'V <br /> - - �) (AJA -e, <br /> - IQ, r4_ <br /> City&'M_��tatec�:Zip Bus. PIM3_410 �LPOAlt. Ph. <br /> hereby state that the above information is current,true and correct to <br /> the best'of my knowledge And agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of th e <br /> commissary is discontinued,the permit,polder must notify the EHD. Failure to notify this office may result in permit <br /> Signature Ok- Date <br /> A IL <br /> Commissary Nam <br /> Address -7 n us. Phone <br /> Ci �/ Ovvne�Openato <br /> Check all appropriate services provided: <br /> otovvatmrdispose| 0/'3-connparLnnentnink [P"E|eothcm| hook,upa <br /> 68o|idwaste disposal E;~[:�oodpreparo1ion ;PTNi|atand handvveshinQ <br /> CV-°4-t & Cold water for cleaning 0 Store refrigerated food 0-15-�tab|evvater <br /> e d food sup I' vernight parking E3-Vehicle wash <br /> hereby state that the information | have provided iscurrent,true and <br /> correct�--- , thebeotofmvknowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the ozune or this agreement, or if this agreement /s modi d or cancelled, he <br /> commmsary <br /> Signatu �f= ate 12- ) s 1 <br /> The commissary is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHOifthe status oftheir operating permit changes. <br /> REMS Signature— Date <br /> 18O8E. Hazelton Avenue I Stockton. California 852O5 | T 209468'34201 F 2094S4-U138 1ommm.sjgov.org/s�,t <br />